Persius/hicric huggingface dataset:
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 the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
record indicates that the enrollee has chronic hypercapnic respiratory failure from chronic obstructive 
pulmonary disease.  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. The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the right-side removal procedure. We decided that the Plan does 
not have to pre-approve the left-side removal procedure.  
 
You asked the Plan to pre-approve the removal of breast implants (19371, 19328). You say that this service is 
medically necessary. The Plan says that code 19371 is not supported. The procedure is not medically necessary. 
 We decided that the Plan has to pre-approve the right-side removal procedure.  
 
The Plan follows Medicare rules. Medicare rules say that the removal of breast implants for a patient who has 
had an implant(s) placed for reconstructive or cosmetic purposes is covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the removal of breast implants. Our 
reviewer says that the right-side procedure is medically necessary. Our physician reviewer found the record 
indicates that the enrollee has bilateral silicone implants with grade IV contracture bilaterally and right implant 
rupture. The elements of the coverage criteria for the right sided procedure are 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 the removal of breast implants have been met. Therefore, we decided that the 
Plan has to pre-approve the right-side removal procedure.  
 
We also decided that the Plan does not have to pre-approve the left-side removal procedure. 
 
The Plan follows Medicare rules. Medicare rules say that the removal of breast implants for a patient who has 
had an implant(s) placed for reconstructive or cosmetic purposes is covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the left-side removal procedure. The 
record does not indicate that the left-side contractures are painful and are disfiguring. The elements of the 
coverage criteria for the left-sided procedure 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 the left-side removal procedure. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the left-side removal procedure. 
 
In order to be covered, the claim for the approved service must be submitted using the appropriate procedure 
codes. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and effectiveness. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a punctal closure procedure to be provided by an out-of-
network (OON) ophthalmologist. 
 You asked the Plan to pre-approve the OON ophthalmic procedure. You say that you have been seeing this 
provider for many years and were told that they would be covered by this Plan. You even had your prior two 
visits this year covered and feel that this procedure should also be covered. The Plan denied your request. The 
Plan says there is no network deficiency as network providers able to perform this procedure are available. 
There is no medical need for this to be performed by the OON provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON ophthalmic procedure. Our 
reviewer says that the documentation does not support that it is reasonable and necessary for this procedure to 
be performed by the OON provider. Our physician reviewer found there are available in-network Providers that 
can perform the standard punctal closure procedure.  This is a standard minor procedure that is performed by 
majority of Ophthalmologists / Oculoplastic specialists.  This is not considered an urgent procedure, and as it 
can be performed by an in-network plan Provider, the requested out-of-network 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 OON ophthalmic procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a punctal closure procedure to be provided by an out-of-network (OON) 
ophthalmologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80503 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 80503. The Plan denied your request. The Plan says payment for 
code 80503 is bundled into payment for code 84166. 
 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 80503 
is a column II code to column I code 84166. 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 80503 billed for date of service August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kenevo microprocessor knee. 
 
You asked the Plan to pre-approve a Kenevo microprocessor knee. 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 a fluid, pneumatic, or electronic/microprocessor knee 
(L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. 
 
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 Kenevo microprocessor knee. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested K3 
microprocessor knee is Kenevo. Ottobock Kenevo microprocessor knee (L5848, L5845, L5856, L5828) 
exceeds the enrollee's medical needs and does not meet Medicare medically necessary criteria per the 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. The requested microprocessor knee has features such as intuitive 
use of a stationary indoor bicycle, adjustments from a smartphone with the Cockpit app, and convenience 
features of charging without removing the foam cover. The physician documentation does not reveal that the 
enrollee requires a microprocessor knee K3 level knee. The enrollee's functional level and use of wheelchair 
does not support K3 level. The Kenevo has deluxe features which exceed the enrollee's needs. 
 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 Kenevo microprocessor knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Kenevo microprocessor knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that a crown is medically necessary. The Plan denied your 
request. The Plan says the requested service is not a covered dental benefit. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
medical criteria for a crown for tooth #13. Our physician reviewer found tooth #13 has an existing crown in 
place that does not show any signs of defects or decay around its margin to require replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
power wheelchair. 
 
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. Our reviewer says 
that the enrollee does not meet criteria for a power wheelchair. Our physician reviewer found the enrollee is 
non-ambulatory and cannot use a cane or walker for mobility. He cannot independently propel a manual 
wheelchair due to upper extremity weakness and lack of endurance. The enrollee cannot operate a power 
scooter due to impaired sitting balance and impaired ability to transfer. He requires a power wheelchair for mobility and accomplishing his daily activities. However, the clinical documentation is insufficient why a 
lower-level power wheelchair would not suffice for his needs. There is inadequate clinical documentation 
regarding why he requires power tilt and recline and cannot perform pressure relief. He is noted to have 3/5 
motor strength in the upper extremities and no history of skin breakdown. There is also no significant lower 
extremity edema or spasticity that would require power elevating leg rests. Lastly, it is not clear if the enrollee 
can safely operate the requested power wheelchair. Therefore, the Jazzy carbon power wheelchair with power 
tilt and recline and power elevating leg rests 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that physical therapy in a skilled nursing facility or 
outpatient therapy is not enough to get them back to where they were. You say that the enrollee will need 
physical therapy and occupational therapy. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollees needs can be met at a lower level of care. 
 
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 enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued 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 at the time of admission, you required skilled rehab services to 
improve function due to weakness and deconditioning. There were no skilled nursing needs. As of last covered 
day, you did not require any skilled nursing or rehab services on a daily basis. You were not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. You did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient 
basis, at a skilled level of care as of 12/3/22. You did not have any parental medications, complex wound care 
or nutrition given via a feeding tube. Your function was at or near your new baseline level of function and you 
could be discharged to a lower level of care for further services. As of 12/3/22, you required custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued 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 home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary and life threatening. The Plan denied your request. The Plan says the device you are requesting will not be used in BiPAP mode. Other types of
breathing machines can provide the support you need. Medicare does not provide the requested type of breathing device for portability access alone. You may discuss this with your provider, and they can send more records. Under Medicare, the request is not medically necessary.

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 have severe obesity and obesity-hypoventilation syndrome. There is a listed diagnosis of COPD, but there are no pulmonary function tests to confirm, and no emphysema on chest CT. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. ABGs during recent hospitalization for exacerbation of HFpEF were consistent with acute on chronic hypercarbic respiratory failure. You likely have chronic CO2 retention and may benefit from BiPAP during sleep. There is no documented failure of BiPAP as an outpatient.  If you do have severe COPD, BiPAP in AVAPS mode would be appropriate. 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 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 enrollee needs to continue with aggressive 
inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not require an intensive 
level of therapy requiring physician oversight. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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.