Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in VAPS mode 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee is on CPAP and 
supplemental oxygen at baseline with a recent diagnosis of acute on chronic respiratory failure due to a chronic 
obstructive pulmonary disease exacerbation requiring hospitalization, intravenous steroids, and antibiotics as 
well as BiPAP therapy. Provided records document that the home ventilator is being requested for use in 
targeted tidal volume, pressure support mode with expiratory positive airway pressure which could be provided 
by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. As stated in 
the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee was diagnosed with muscular 
disease & progression is moving fast so he cannot have it removed or he will end up in ICU. The mod for 
ventilator use was clearly marked in the physician form, mode IVAPS. The Plan denied your request. The Plan 
says the request is not medically necessary. The records do not show that the requested device will not be used 
exclusively in CPAP or bi-level PAP mode. 
 
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 the enrollee has a diagnosis of 
amyotrophic lateral sclerosis, a neuromuscular disease. Provided records document that the home ventilator is 
being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-titration (AE) 
which could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a 
back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide 
CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable 
and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (iovera system). 
 
You asked the Plan to pre-approve destruction by neurolytic agent; other peripheral nerve or branch 
(iovera system). You say that destruction by neurolytic agent; other peripheral nerve or branch (iovera system) 
is medically necessary. The Plan denied your request. The Plan says destruction by neurolytic agent; other 
peripheral nerve or branch (iovera system) is considered experimental. 
 
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 destruction by neurolytic agent; other 
peripheral nerve or branch (iovera system). Our reviewer says that the requested iovera system is not 
considered medically reasonable and necessary. Our physician reviewer found the iovera technology is a 
non-opioid and non-systemic treatment for blocking pain signals from peripheral nerves. According to 
Medscape Internal Medicine 2017, the US Food and Drug Administration (FDA) has cleared the iovera device, 
from Myoscience, Inc, for the relief of pain and symptoms associated with knee osteoarthritis (OA).  However, the information available about iovera indicates that the safety and effectiveness of the procedure is unproven. 
The requested iovera procedure/system is considered experimental and investigational. Medicare coverage 
guidelines state that a service can be considered reasonable and necessary if it is safe and effective and not 
experimental or investigational. Based on review of abstracts of peer-reviewed literature, there is insufficient 
evidence to inform conclusions regarding the iovera system.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent; other peripheral nerve or branch (iovera 
system) have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent; other peripheral nerve or branch (iovera system).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral nutrition pump rental provided on August 11, 
2022. 
 
You asked the Plan to pay for the enteral nutrition pump rental. You say that this was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is missing required modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that rented equipment is identified with modifier -RR 
and modifier -KH, -KI, or -KJ, depending on the month in the rental period.  
 
 
 
 
 
 
 
  
We looked at the file and Medicare rules. A required K modifier was not reported on this claim. Based on this 
information, we decided that Medicare rules for coverage of the enteral nutrition pump rental have not been 
met. Therefore, we decided that the Plan does not have to pay for the enteral nutrition pump rental provided on 
August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies (A4239, E2103). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that you need this CGM to 
keep up with your glucose levels. This is critical to your life, and you prick your finger to check his blood 
glucose. The Plan denied your request. The Plan says the Medicare guidelines say that CGM devices that solely 
display results on a smartphone and do not have a stand-alone receiver or integration into an insulin infusion 
pump do not meet the definition of durable medical equipment (DME) and will be denied as non-covered (no 
benefit). 
 
 
 
 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 Freestyle 
Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies (A4239, E2103).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on October 
20, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 delivery 
documentation is not itemized. 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 electrical 
stimulator supplies (A4595) provided on October 20, 2022.
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 it is felt that LTACH care is needed. The 
Plan denied your request. The Plan says current facility can meet the enrollee's needs. 
 
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 a male who was admitted with intracranial hemorrhage with seizures, 
and atrial fibrillation. Recent notes describe the enrollee as still on Cardizem drip with guarded prognosis. The 
enrollee appears to still be unstable and requires additional acute care services that can safely be provided at the 
current facility until more stable for transfer. The enrollee does not require services at the LTACH that are not 
already available at the current facility.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you need to be approved so you can 
continue to receive your supplies for your monitor to maintain your levels. The Plan denied your request. The 
Plan says you do not require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable underpads (A4554) and adult sized 
disposable incontinence product, brief/diaper (T4523). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medicare criteria for medical supplies do not cover items that can't be 
reused. The requested supplies are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable underpads (A4554) 
and adult sized disposable incontinence product, brief/diaper (T4523).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Zilretta. 
 
You asked the Plan to pay for Zilretta. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Zilretta. Our reviewer says that the 
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer 
found you have osteoarthritis of the right knee. You have been treated with medication and received a Zilretta 
injection in November 2022. Based on the Label, it does not preclude use of the drug more than one time. The 
documentation supports that a repeat Zilretta injection for the knee is medically reasonable and necessary and 
is safe and effective for you. Therefore, you meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pay for 
Zilretta.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to regain maximum strength to lead a 
normal life and denial of this request will seriously jeopardize the goal. The Plan denied your request. The Plan 
says your records do not show that you need an intensive team for your 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for sepsis and renal abscess. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
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. The Plan denied your request. The Plan says the records show that 
the enrollee's rehabilitation is not complex and does not require an intensive and coordinated interdisciplinary 
approach to rehabilitation, medically necessary care may be provided safely in a different 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 the enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an office visit to be provided by the requested physician. 
 
You asked the Plan to pre-approve the office visit to be provided by the requested physician. You say that the 
services with this physician are medically necessary. The Plan denied your request. The Plan says that the Plan 
did not receive the transition of care (TOC) coverage request within 90 days. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with a Plan rule or a Medicare rule to 
substantiate the denial. Therefore, we decided that the Plan has to pre-approve an office visit to be provided by 
the requested physician. 
 
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 a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the ventilator is necessary. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, are 
not covered. 
 
We looked at 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).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot feature and extra knee suspension 
(L5670, L5981). 
 
You asked the Plan to pre-approve an advanced foot feature and extra knee suspension. 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 lower limb prostheses 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 an advanced foot feature and extra knee 
suspension. Our reviewer says that the services are not medically necessary. Our physician reviewer found an 
advanced foot feature and extra knee suspension are not medically necessary. The requested items exceed the enrollee's medical need. The documentation does not reveal extenuating factors that require two suspension 
systems for single approved prosthesis. The enrollee was already approved for an L5671 suspension lock 
mechanism. The documentation does not reveal that the enrollee is a K3 ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot feature and extra knee suspension have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature and extra knee 
suspension (L5670, L5981).