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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has COPD and chronic 
respiratory failure which has led him to admissions and exacerbations. The enrollee also has a history have 
obesity hypoventilation syndrome. He requires a ventilator for adequate ventilation and to manage the airway. 
Interruption can cause harm to the enrollee and increase the risk for hospital readmission. The ventilator will 
improve this enrollee's quality of life. The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in AVAPS 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 has COPD, severe 
obesity, obesity hypoventilation syndrome, and a history of substance abuse. He was recently hospitalized with 
acute respiratory failure and bacteremia. An arterial blood gas was consistent with acute on chronic hypercarbic 
respiratory failure. There is no ABG done while stable to document chronic CO2 retention. If the enrollee does 
have chronic CO2 retention, he 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic surgical system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that there is insufficient literature to 
support the safety and efficacy of the requested robotic surgical system compared to standard treatments. The 
records do not support that the robotic surgical system is medically necessary for the approved procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a robotic surgical system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy X-ray absorptiometry (DXA), bone density 
study, 1 or more sites (code 77080) provided on July 19, 2022. 
 
You asked the Plan to pay for the dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more 
sites. You say that the dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites was 
medically necessary. The Plan denied your request. The Plan says with the information we have, we cannot 
determine how the member came to the servicing provider, or whether the services are medically necessary. 
The listing of a referring provider on the claim does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dual-energy X-ray absorptiometry 
(DXA), bone density study, 1 or more sites have been met. Therefore, we decided that the Plan does not have 
to pay for a dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites (code 77080) 
provided on July 19, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87150, 87798 and 87481. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 80050.  
You asked the Plan to pay for laboratory services provided on November 1, 2022. You say that these services 
were necessary and are supported in the medical record. The Plan says that an infectious disease pathogen 
panel should be billed with only one unit of service, and code 80050 is not covered by Medicare. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87150, 87798 and 
87481.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not cite the rule used to deny these services, and we 
were unable to locate this rule in a determination which applies to the state where these services took place. 
The Plan has provided no other reason for denial of these codes. Therefore, we decided that the Plan has to pay 
for the services described by procedure code(s) 87150, 87798 and 87481.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
80050. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 80050. 
 
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 pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided September 9, 2022. 
 
You asked the Plan to pay for the TENS device. You say that per the prescription, the prescribing physician 
recommends an extended lifetime use of equipment as the enrollee is diagnosed with chronic pain and 
compromised mobility without the option for surgical correction. The Plan denied your request. The Plan says 
evidence of misrepresented service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order 
number or details to corroborate the delivery ticket submitted. The proof of delivery is not itemized to indicate 
the specific supplies. Also, as per United States Postal Service (USPS), the packet shows USPS currently 
awaiting package. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical 
nerve stimulation (TENS) device (E0730) provided September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories (E0978, K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the requested wheelchair accessories are not correctly 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes 
the services performed. 
 
We looked at the file and Medicare rules. Armrests are already included with the requested power tilt. The 
requested lap belt is included with the base wheelchair. Specific codes exist for the Shoe Holders and Ankle 
Huggers, arm pads, and arm troughs. Based on this information, we decided that Medicare rules for coverage of 
the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair accessories (E0978, K0108).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided on September 28, 
2022. 
 You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed correctly. 
The Plan denied your request. The Plan says that the documentation does not include a proof of delivery or a 
delivery ticket. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and Medicare rules. The record does contain a valid proof of delivery. The electrical 
stimulator supplies are supported by the records provided because the packing slip and the third-party delivery 
tracking information have a tracking number to link those documents together. The documents meet the 
Medicare rules for valid proof of delivery. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have been met. Therefore, we decided that the Plan has to pay for 
the electrical stimulator supplies (A4595) provided on September 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has tried extensive non-
surgical management with no lasting relief. Surgical intervention was recommended via posterior lumbar 
interbody fusion of L4-5. The Plan denied your request. The Plan says the enrollee does not meet the coverage 
criteria for the added fusion surgery. As the enrollee does not meet criteria for the fusion surgery, the allograft 
for the spinal fusion 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found only the L4-5 decompression surgery is needed for stenosis. There is no spinal instability. The surgery for laminectomy will not destabilize the spine and the fusion is not needed. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
guidelines for an IRF 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 that the clinical documentation shows the enrollee has active medical comorbidities 
however no complex functional impairments have been specified. Thus, 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. Additionally, updated therapy notes do 
not show that the enrollee would tolerate 15 hours of therapy per week. The criteria for an IRF admission have 
not met. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve a cardiac rhythm monitor. You say that medical records were submitted to 
support the medical necessity for the requested service. The Plan denied your request. The Plan says for 
services to be covered they must be medically necessary services, supplies, or drugs that are needed for the 
prevention, diagnosis, or treatment of the enrollee's medical condition and meet accepted standards of medical 
practice. Based upon the clinical notes reviewed, the enrollee does not meet medical necessity guidelines. 
 
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 rhythm monitor. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke, or any other apparent indication for an implantable loop recorder (ILR). In summary, there 
is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's clinical 
management. 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 rhythm monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on September 6, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says the documentation does not include a proof of delivery or a delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. In this case the 
request was submitted for items purchased September 6, 2022. The records include delivery and tracking information related to a purchase delivered on June 6, 2022. Thus, the provided documentation does not 
support the purchase and delivery of the item requested. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry cancer screening (88184, 88185 and 88188) 
provided on August 15, 2022. 
 You asked the Plan to pay for flow cytometry cancer screening. You say that this testing was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says this testing was 
provided as a screening test to an enrollee with no personal history of malignancy, leukemia or lymphoma and 
no constitutional symptoms. This test is not covered as a screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, flow cytometry cancer screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for flow cytometry cancer screening (88184, 88185 and 88188) provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with a podiatrist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says out of network services are not a covered benefit 
when services are available within the enrollee's plan. The service can be provided by an in-network provider. 
 
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 office visit (99203) with a podiatrist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foresee Home eye monitoring device (0379T). 
 
You asked the Plan to pre-approve the Foresee Home device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental and 
investigational. 
 
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 Foresee Home device. Our reviewer 
says that the requested Foresee Home device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Foresee Home monitoring program is considered investigational or 
experimental as additional clinical studies are needed to demonstrate that it affects visual outcomes. Therefore, 
the reviewer found that the Foresee Home monitoring is not medically reasonable or 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 the Foresee Home device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Foresee Home eye monitoring device (0379T).
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 member would benefit from increased intensity of 
therapy. The Plan denied your request. The Plan says criteria for an IRF admission has not been met. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. The member can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.