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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a failed four-week trial of a basic device. 
 
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 the provided records in this case document lymphedema of the neck, face, cheeks, lips, larynx and 
pharynx due to a history of head/neck cancer but do not document lymphedema of the chest, trunk, or 
abdomen. As the records do not document lymphedema of the chest, trunk, or abdomen or a four-week trial and 
failure of a standard pneumatic compression pump, then it cannot be said that the enrollee has unique 
characteristics that would indicate a segmented pump over a standard pump.  
 
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 a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous passive motion (CPM) exercise device 
for use other than knee (E0396). 
 
You asked the Plan to pre-approve the CPM device. You say that this device is medically necessary for you to 
get full use of your shoulder again after shoulder joint repair. The Plan denied your request. The Plan says the 
criteria has not been met as the records show that this device is being requested for care following shoulder 
surgery. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve the continuous passive motion (CPM) exercise device for use other than knee (E0396).
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 member is medically stable and 
meets the criteria for an LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The requested 
service cannot be recommended as the elements of the coverage rules 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 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 wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee needs this device. The Plan 
denied your request. The Plan says a wheelchair ramp is not primarily medical in nature and thus not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
between wheelchair controller and two or more power seating system motors, and a power seat elevation 
system. 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and a power seat 
elevation system. You say that the services are necessary. The Plan denied your request. The Plan says based 
on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories 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 expandable controller, harness, 
electronic connection, and a power seat elevation system. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found provided records document that the enrollee has 5/5 upper extremity 
strength and is independent with eating, dressing, bathing and grooming thus indicating he has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. The 
requested power seat elevation feature is statutorily non-covered as it serves no primary medical purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, electronic connection, and a power seat 
elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller, harness, electronic connection between wheelchair controller and two or more power 
seating system motors, and a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeve 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member does not have lymphedema extending onto 
the chest, 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 has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652) and sleeve (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve an extra knee stance. You say that the enrollee's prosthetic is more than five 
years old, and the knee is no longer under warranty. The bushings are worn out and the knee hydraulics are 
failing. The knee must be replaced for safety. The Plan denied your request. The Plan says the extra knee 
stance feature is unbundled from the approved code L5814. The request does not meet the Medicare or Plan's 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code L5845 is not supported in the medical record and is unbundled from the approved code 
L5814. Specifically, the policy article confirms that the L5845 additional feature and/or function does not 
describe a complete endoskeletal knee-shin system. The stance feature is already included with the approved 
knee. Records show that neither the manufacturer nor the vendor have the authority to assign code L5845 to the 
requested knee. Based on this information, we decided that Medicare rules for coverage of an extra knee stance 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal, 
knee-shin system, stance flexion feature, adjustable (L5845).
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 do not 
show the need for an intensive program with a team of health care professionals and doctors that specialize in 
complex medical needs and interdisciplinary team approach to the delivery of rehabilitation 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 the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are necessary because you had a 
stroke, and have difficulty with speaking, walking, and reading. You cannot care for yourself and do not feel 
safe going home. The Plan denied your request. The Plan says the requested SNF services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
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's current condition and functional 
deficit, and multiple comorbidities meets full inpatient acute rehabilitation criteria. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met, 
ongoing skilled therapy and nursing needs can be provided at a lower level of care, a Skilled Nursing Facility, 
on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer (22869, 
22870). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that you feel the enrollee is an 
excellent candidate for this minimally invasive procedure and should have access based on medical necessity 
and strong level1 clinical evidence supporting the efficacy and safety of this procedure. The Plan denied your 
request. The Plan says this service is considered experimental and investigational as there is a lack of evidence 
to support that interspinous spacer devices are as safe and effective as the gold standard of decompression. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion interspinous spacer (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on July 15, 2021. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay these services, because 
you called your insurance prior to having the services and you were told they would be covered. Once you had 
the services completed, you received a bill. The Plan denied your request. The Plan says this service is not 
covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Comprehensive periodontal 
evaluation - new or established patient (D0180) is not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive 
periodontal evaluation - new or established patient (D0180) provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item 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 portable ventilator. Our reviewer says 
that the member does not need this item. Our physician reviewer found arterial blood gases (ABG) have shown 
various degrees of carbon dioxide (CO2) retention and have been consistent with mild acute on chronic 
hypercarbic respiratory failure. However, there are no ABGs done while stable to confirm chronic CO2 
retention. The patient previously had a home ventilator that was reclaimed because of noncompliance. This 
patient may benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep if compliance issues can be addressed. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous basivertebral 
nerve (BVN) for vertebrogenic lower back pain is not medically necessary when there is a previous 
lumbar/lumbosacral spine surgery at the intended treatment level. 
 
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 Intracept procedure. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the case file contains 
documentation of previous lumbar/lumbosacral spine surgery at the intended treatment levels. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 you are scheduled to be discharged soon, and your 
right leg and knee are causing you issues, and your knee is buckling. The Plan denied your request. The Plan 
says youre not meet the criteria for inpatient rehab facility admission. 
 
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, rehabilitation, and medical needs does not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-the-bed table (E0274). 
 
You asked the Plan to pre-approve an over-the-bed table. You say that you are paralyzed on your left side. You 
say that you do not feel safe with things sliding across your tray. You also say that this is medically necessary 
for you. The Plan denied your request. The Plan says an over-the-bed table is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-the-bed table (E0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items do not meet the coverage criteria. 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has adequate upper body strength to manage the standard switches on a power 
wheelchair. This request exceeds what is necessary to meet 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).