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

 
We decided that the Plan does not have to pre-approve the walker, folding, wheeled, adjustable or fixed height 
(E0143) and walker seat attachment (E0156). 
 
You asked the Plan to pre-approve the walker. You say that the medical records support the necessity of the 
requested items. The Plan denied your request. The Plan says the enrollee has had similar DME previously 
approved by the Plan in 2022, that in good condition, less than 5 years old for the same medical need, therefore 
this equipment is not covered. 
 
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 you have E0143 and E0156. The records show this was approved by the Plan on 
09/06/2022. E0143 and E0156 serves the same purpose as the walker. Therefore, we decided that the Plan does 
not have to pre-approve the walker, folding, wheeled, adjustable or fixed height (E0143) and walker seat 
attachment (E0156).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. The Plan denied your request. The Plan says that the 
notes do not show that you had treatment goals. A written treatment plan is required. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that the service is medically necessary. Our physician reviewer found you are noted to have decreased strength 
in the lower extremities, a history of falls, and require a manual wheelchair or assistive device for mobility. 
You also require assistance with transfers. Treatment goals were provided in terms of improving your timed up 
and go score and decreasing your risk for falling. Physical therapy and the skills of a physical therapist would 
be appropriate to improve your mobility and minimize fall risk. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve physical therapy services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious agent detection panel provided to the enrollee 
on November 18, 2021. 
 
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. 
The Plan says there are no documented symptoms, vital signs, physical findings, severity evidence or 
assessment. 
 
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 pay for the panel. 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 do not document a clinical indication in which there is a presumption of active 
infection or infection-associated complications (which may include exacerbation of underlying disease) that 
require the identification of a causative organism for appropriate management and the specific reasons for 
performing panel testing (as opposed to targeted testing) as required by the Local Coverage Determination 
(LCD). 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for an infectious agent detection panel provided to the enrollee on November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the requested Euflexxa injections. You say that it is felt that the requested 
treatment is needed. The Plan denied your request. The Plan says the Plan preferred agents can be used for this 
treatment. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Euflexxa injections. Our 
reviewer says that the requested drug is not medically reasonable and necessary based on step therapy criteria. 
Our physician reviewer found the enrollee is noted to have osteoarthritis. A request has been made for 
Euflexxa, a hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of 
hyaluronic acid be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of 
medication. There is no evidence that the enrollee has tried and not responded to these other forms of 
medication. There is no documentation as to why these other forms of medication would not be expected to be 
safe and effective for the enrollee. Therefore, the requested Euflexxa is not shown to be currently medically 
necessary and reasonable. 
 
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 Euflexxa injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary 
for the enrollee's condition after surgery. The Plan denied your request. The Plan says this equipment is not 
covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Epifix skin graft application. 
 
You asked the Plan to pre-approve the Epifix skin graft application. You say that the Epifix skin graft 
application is medically necessary. The Plan denied your request. The Plan says the Epifix skin graft 
application is not medically necessary. 
 
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 Epifix skin graft application. Our 
reviewer says that the requested Epifix skin graft application is not considered medically reasonable and 
necessary. Our physician reviewer found there is insufficient evidence that you have fully exhausted other 
means of treatment that are more appropriate and proven for decubitus ulcers such as more aggressive 
offloading and wound VAC use. Therefore, this request for Epifix skin grafting will be considered not 
medically necessary 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 Epifix skin graft application have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Epifix skin graft application.
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 the enrollee would benefit from and can tolerate an 
intensive interdisciplinary treatment program with three hours of therapy five days per week under the 
supervision of a physician. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's 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 has no acute decline in musculoskeletal or neurological function. 
The enrollee does not require intensive rehabilitation or frequent physiatry oversight. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal home care. 
 
You asked the Plan to pre-approve personal home care. You say that you need help at home with cleaning, 
washing, and organizing your belongings. The Plan denied your request. The Plan says the services are not 
covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of personal home care have not been met. The rules say that services 
for which the sole purpose is to enable the patient to continue residing in their home (e.g., cooking, shopping, 
Meals on Wheels, cleaning, laundry) are excluded from home health coverage. Therefore, we decided that the 
Plan does not have to pre-approve personal home care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and attendant 
control system (E2331). 
 You asked the Plan to pre-approve a power seat elevation system and attendant control 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 if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-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 power seat elevation system and 
attendant control system. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the enrollee is noted to be able to operate the requested power wheelchair and there is insufficient 
documentation indicating why he would require an attendant control system. Additionally, the power seat 
elevation feature is considered not to be primarily medical in nature. 
 
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 seat elevation system and attendant control system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and 
attendant control system (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions and tori removal to prepare for 
denture placement to be provided in a hospital setting. 
 
You asked the Plan to pre-approve the hospital-based dental surgery services. You say that these services are 
necessary and should be approved. The Plan denied your request. The Plan says these were requested as 
medical services. Medicare does not cover dental extractions and surgery for preparation for dentures. These 
may be requested in another setting under the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services were 
not requested with American Dental Association (ADA) codes. The medical codes used in the request cannot 
be approved as Medicare does not cover these services. You may wish to contact your provider to determine if 
these can be requested with ADA codes from your dental supplement. Therefore, we decided that the Plan does 
not have to pre-approve dental extractions and tori removal to prepare for denture placement to be provided in 
a hospital setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device (CPT code L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says medical studies have not proven this service/item is helpful for the treatment of the 
enrollee's health problem. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
Although records from the device manufacturer/vendor argue medical necessity of the requested device, 
records from the enrollee's actual treating provider do not clarify why the requested device is the most 
appropriate treatment for the enrollee's condition as required by Social Security Act, Section 1862(a)1(A). In 
addition, provided records report left upper extremity spasticity which may be a contraindication to use of the 
device. 
 
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 the MyoPro orthotic device (CPT code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable under pads, all sizes (A4554) gloves, non-
sterile, per 100 (A4927) hygienic item or device, disposable or non-disposable, any type (A9286) adult sized 
disposable incontinence product, brief/diaper, extra-large, each (T4524). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the records support the necessity of the 
requested items. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 under pads, all sizes 
(A4554) gloves, non-sterile, per 100 (A4927) hygienic item or device, disposable or non-disposable, any type 
(A9286) adult sized disposable incontinence product, brief/diaper, extra-large, each (T4524).
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 ventilator. The Plan denied your request. The Plan says the type of 
breathing help can be provided with a different device. 
 
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 ventilator. Our physician reviewer 
found that medical records report a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. No arterial blood gas results are included in the records to support this diagnosis. The home 
ventilator is being requested for use in volume assured pressure support mode with auto-titration (AE) which 
could be provided by a BiPAP device. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
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 it is felt that IRF care is needed. The Plan denied 
your request. The Plan says the enrollee's needs can be met in a lesser 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 enrollee was admitted to an acute hospital on 12/12/22 with worsening confusion 
from a nursing facility. She had a fall on 12/8 sustaining multiple compression fractures. The enrollee is medically improving and does not need a physician's close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute 
nursing needs documented. The enrollee will not tolerate and make a significant functional improvement in 7-
10 days in an IRF and does not need 3 hours a day x 5 days a week of therapies with multidisciplinary 
approach 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the requested Eylea is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Lucentis first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Eylea. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.