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

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a BiPAP device only gives one-third the flow of a 
non-invasive ventilator and does not have an internal battery or alarms. The Plan denied your request. The Plan 
says a ventilator is not covered by Medicare for this purpose and the needed therapy could be delivered by a 
BiPAP device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide CPAP or 
BiPAP therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 enrollee would benefit from an 
admission to LTACH to regain maximum/prior level of functioning. The Plan denied your request. The Plan 
says the enrollee records do not show that it is safe to go to the LTACH and may safely receive care at the 
current acute care facility. 
 
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 continues to require care in an acute care hospital and can receive further 
care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional OT visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that the enrollee needs to be monitored closely 
due to recent illness that has furthered the deconditioning. The Plan denied your request. The Plan says the 16 
occupational therapy visits are denied because they are not medically necessary. 
 
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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is functioning at a home care level for rehabilitation and 
does not require daily skilled therapy or a stay in an extended care 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 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional OT visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda) (J9271). 
 
You asked the Plan to pre-approve the medication. You say that because of progression of disease while on 
chemoradiation and borderline performance status; it has been recommended that the enrollee proceed with 
single agent pembrolizumab (Keytruda). The Plan denied your request. The Plan says Keytruda for the 
treatment of metastatic non-small cell lung cancer is not FDA-approved treatment and is not listed as medically 
accepted in the drug information resources approved by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the criteria are not met, because compendia literature and FDA label approval requires at least a PDL1 of 
1 percent. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab (Keytruda) (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 14 day sensor. The Plan denied your request. The Plan 
says the enrollee does 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 that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 14 day sensor  have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 day sensor.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87500. We decided that the Plan does not have to pay 
for procedure codes 87150-59, 87481-59, 87491-59, 87591-59, 87640-59, 87641-59, 87653-59, 87798-59.  
 
You asked the Plan to pay for the lab testing services provided on August 21, 2021. The Plan says that the 
billed services cannot be verified. 
 
We decided that the Plan has to pay for procedure code 87500.  
 
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 procedure code 87500 is supported. Code 87500 is a column I code to column II code 87150. A 
modifier is not required with code 87500 to bypass an edit. The medical records do confirm that the testing was 
provided. Based on this information, we decided that the Medicare rules for coverage have been met. 
Therefore, we decided that the Plan has to pay for procedure code 87500 provided on August 21, 2021.  
 
We also decided that the Plan does not have to pay for procedure codes 87150-59, 87481-59, 87491-59, 
87591-59, 87640-59, 87641-59, 87653-59, 87798-59. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.  
 
We looked at the file and the rules. The file shows that the enrollee received a urinary tract infection panel. The 
medical records provided do not show that the codes billed with the -59 modifier were distinct procedural 
services. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150-59, 87481-59, 87491-59, 
87591-59, 87640-59, 87641-59, 87653-59, 87798-59 provided on August 21, 2021. 
 
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 an insertion of pacing electrode, cardiac venous system, 
for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator 
(33225). 
 
You asked the Plan to pre-approve a cardiac implantable device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee has therefore demonstrated on his own over the last 2 
years that RV pacing is not medically necessary for him. The addition of a left ventricular lead and upgrade to 
CRT-P pacing 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 a cardiac implantable device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the appropriateness and medical necessity of implanting a CRT-
P system in this enrollee. Echocardiogram has showed normal ejection fraction of 55-60% despite 100% RV 
pacing. As such, 2021 AHA/ACC guidelines do not recommend CRT-P in such enrollees. In summary, there is 
insufficient documentation to support the medical necessity for placement of a bi-ventricular pacemaker. 
 
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 cardiac implantable device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of pacing electrode, cardiac venous system, for left ventricular 
pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (33225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for the billed service. You say that this is a separate service from the surgical claim. 
The Plan denied your request. The Plan says payment for the service is included with minor procedure 21320. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 99221 is included with payment for procedure code 21320. The visit was not billed 
with a valid modifier suitable for separate payment. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99221 billed for date of service September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the records show medical necessity. The Plan 
denied your request. The Plan says the rules for payment have 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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient. 
 We find that CPT code 99205 is not supported. The enrollees claim information shows that a new patient visit 
was provided by a physician of the same specialty in the same group practice within the last three years. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99205 billed for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 97530, 97110, 97012, and 98941 provided August 9, 
2022, to September 1, 2022. 
 
You asked the Plan to pay for codes 97530, 97110, 97012, and 98941. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for codes 97530, 97110, 97012, and 98941 provided August 9, 2022, to 
September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal 
knee-shin system, microprocessor control feature, swing, and stance phase, includes electronic sensor(s), any 
type (L5856). 
 
You asked the Plan to pre-approve lower extremity prosthesis. You say that the enrollee currently has a well-
healed residuum limb that is ready to begin ambulatory weight bearing forces. The enrollee is highly motivated 
to ambulate and engaged in physical therapy. The enrollee has been established as a K3 level. The Plan denied 
your request. The Plan says the enrollee does not meet the medical necessity criteria for the requested durable 
medical equipment (DME) item. 
 
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 lower extremity prosthesis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a recent AKA. Her functional status has not been 
measured. There is no physical therapy (PT) evaluation, no record of PT and no direct observation of her 
functional status. Per LCD L33787, as there is only assertions, she will be a K3 ambulator. No observation or 
direct evaluation of the enrollee's current status is provided to support that assertion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing, and stance phase, includes electronic sensor(s), any type (L5856).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cant get up and walk, more 
rehabilitation is needed. The Plan denied your request. The Plan says the enrollee's records do not show the 
need for required daily skilled nursing or daily skilled rehabilitation services on an inpatient 
basis in a skilled nursing facility. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tablet cutter (E1399). 
 
You asked the Plan to pre-approve a tablet cutter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is for convenience and not medical in nature. 
 
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 tablet cutter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 and 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 Dexcom 
G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
sensor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy, extracellular fluid analysis 
for lymphedema assessment(s) (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is experimental and 
investigational and is not 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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bioimpedance spectroscopy devices for detection of lymphedema are 
considered investigative and unproven. There is insufficient reliable evidence in the form of high-quality peer-
reviewed medical literature to establish the efficacy or effects on health care outcomes. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy, extracellular fluid analysis for lymphedema 
assessment(s) (93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intra-uterine device (IUD). 
 
You asked the Plan to pre-approve IUD. You say that you need this in order to prevent any pregnancy that 
would pose severe risk. The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-
approve an intra-uterine device (IUD).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. The Plan denied your request. 
The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered 
for the indications established in the applicable LCD. 
 
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 spinal electrical osteogenesis 
stimulator. Our reviewer says that the requested spinal electrical osteogenesis stimulator is medically 
reasonable and necessary in this case. Our physician reviewer found that there has not been a minimum of 9 
months since the last surgery. Additionally, there is no history of a previously failed fusion. However, the 
lumbar fusion was noted to be at the L4-L5-S1 levels. This corroborates a multilevel spinal fusion, which meets 
criteria #2. Therefore, the requested spinal electrical osteogenesis stimulator (E0748), in this case, is medically 
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 spinal electrical osteogenesis stimulator have been met. Therefore, we decided 
that the Plan has to pre-approve a spinal electrical osteogenesis stimulator (E0748).  
 
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.