Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a positron emission tomography (PET) scan of the brain. 
 
You asked the Plan pre-approve the PET scan. You say that the enrollee is suffering from a major 
neurocognitive disorder. You say a PET scan of the brain has been requested as a biomarker for further 
diagnostic information. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the requested service is covered for use in 
individuals who meet diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. The 
records provided for review did not indicate that the enrollee met diagnostic criteria for either condition. The 
base requirement for coverage of this service has not been met at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (44140) provided on August 23, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 44140 is partial colectomy with anastomosis. 
 
We find that CPT code 44140 is not supported in the medical record. Specifically, the Operative report does 
not include enough information to confirm a partial colectomy with anastomosis. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (44140) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral. 
 
You asked the Plan to pre-approve the referral. You say that you have previously seen this provider and want to 
see them again. The Plan denied your request. The Plan says services are available from several in-network 
providers within 25 miles of your home address. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an armchair with a seat lift mechanism (E1399). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested Golden tech armchair is not 
considered to be DME. It is an armchair that jolts the enrollee from a seating to standing position. 
 
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 armchair with a seat lift mechanism (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records show that the noninvasive ventilator has been prescribed to be used 
exclusively in the bilevel positive airway pressure (BiPAP) setting. 
 
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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the patient 
was recently hospitalized with acute on chronic hypercarbic respiratory failure.  There are diagnoses of severe 
obesity, obesity hypoventilation syndrome, chronic kidney disease stage IV, and heart failure with preserved 
ejection fraction (HFpEF). The enrollee improved with bilevel positive airway pressure (BiPAP), and then 
average volume-assured pressure support-automated expiratory positive airway pressure (AVAPS-AE). 
Pulmonary function tests in 2016 were reported as showing restrictive lung disease, without obstruction. There 
is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. AVAPS-AE can be provided with certain BiPAP devices. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 29, 2022, 
to August 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this admission was 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the member was admitted in stable condition and there was not a reasonable 
expectation that the care would need to span 2 or more 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 pay for the acute inpatient hospital care provided August 29, 2022, to August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an IRF admission due to 
decreased strength and de-conditioning from a prolonged hospital stay. The Plan denied your request. The Plan 
says the requested IRF admission is not medically necessary. 
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for septic shock, cardiac arrest, and respiratory failure. Your medical problems are stable and there are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have 
a need for physical therapy 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair and mechanism. 
 You asked the Plan to pre-approve a seat lift chair and mechanism. You say that you have trouble getting out of 
the chair you currently have. The Plan denied your request. The Plan says that the seat lift mechanism is not 
medically necessary. The Plan also says that the lift chair is not covered. 
 
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. The rules also say that seat lift chairs 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 seat lift mechanism. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the request is not for 
medically necessary indications of severe arthritis or a neuromuscular condition which prevents you from 
rising from a chair. 
 
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 seat lift mechanism have not been met. Although a seat lift chair may be 
appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that 
Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and 
mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure improves the enrollee's 
quality of life. The Plan denied your request. The Plan says the coverage criteria have not been met. 
 The Plan follows Medicare rules. Medicare rules say that thermal destruction of the basivertebral nerve is only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found the enrollee has a diagnosis of spondylosis without myelopathy or radiculopathy, lumbar 
region. The enrollee has vertebrogenic pain, and chronic pain syndrome. Radiofrequency ablation and multiple 
interventional pain procedures have failed in the past. The documentation does not support that there is 
evidence of Type 1 or Type 2 Modic changes on MRI. There is insufficient support that intraosseous ablation 
of the basivertebral nerve is indicted for the enrollees condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
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 BiPAP therapy will be insufficient for this 
enrollee. The enrollee requires at least 3 liters of oxygen continuously around the clock. The enrollee would 
benefit from customized volume ventilation and the auto-exhale feature the NIV provides over the BiPAP. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with 
Auto-EPAP (AE) 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 was recently hospitalized 
with acute on chronic hypercarbic respiratory failure. There are diagnoses of severe COPD and severe obesity. 
The enrollee improved with BiPAP and then AVAPSAE. Pulmonary function tests (spirometry) were 
consistent with severe combined obstructive and restrictive lung disease. A reduced maximum inspiratory 
pressure was found, but there is no documentation of neuromuscular disease or diaphragmatic dysfunction. 
This enrollee may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
and power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration 
for the medically required equipment for the enrollee. The Plan denied your request. The Plan says although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The seat elevator does not serve a primary medical purpose 
and is statutorily non- covered. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee as adequate strength to manage standard power drive switches on the 
approved power wheelchair. The request exceeds what is necessary to meet the enrollees 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) harness (E2313) electronic connection between 
wheelchair controller and two or more power seating system motors (E2311) and power seat elevation system 
(E2300).
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 are requesting an expedited reconsideration for 
the denial of an IRF admission stating the enrollee meets full criteria. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for an IRF stay. 
 
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 nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee currently has a CPAP device that 
must be checked out in person by the supplier and found that it cannot be repaired. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was approved for a CPAP device and supplies on August 11, 2020. This CPAP 
device serves the same purpose as the requested CPAP device. The records show that the provider will need to 
submit notes showing the current CPAP device cannot be repaired. Therefore, we decided that the Plan does 
not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
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 to help manage the enrollee's 
complicated respiratory needs at home. The Plan denied your request. The Plan says the request for a home 
mechanical ventilation set in AC mode with very low tidal volumes 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 has severe COPD. The 
Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory support. Its 
intended use is during activity, and not to treat nocturnal hypoventilation and CO2 retention. There is 
inadequate evidence of the safety and effectiveness of this device in the treatment of COPD. 
 
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 pay for the services (95912, 95886) provided on August 11, 2022.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 95912 is "Nerve conduction studies; 11-12 studies". 
 
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 use of code 95912 is 
not supported by the records provided. Our reviewer found that there is a more appropriate code that captures 
the correct number of studies done. 
 
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. 
 
We have also confirmed that code 95886 is an add-on code. As the primary procedure code is not payable in 
this case, the add-on code is also not payable. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (95912, 95886) provided on 
August 11, 2022.