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

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve the requested device. You say that the device would restore the enrollee's 
arm function and range of motion. The Plan denied your request. The Plan says the device is considered 
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 requested device. Our physician 
reviewer found that the enrollee has left hemiplegia and contracture of left hand and wrist due to 
cerebrovascular accident in 2011. He has engaged in physical and occupational therapy and bracing. The 
enrollee remains with functional deficits. The MyoPro is not the standard of care for this enrollees condition or 
in widespread use for this enrollees condition based on scientific evidence. There is insufficient evidence in 
the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
Therefore, the requested device 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthotic device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on July 18, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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, we have confirmed that code 76942-26-59 is a column II code to column I code 55706 and 76872; 
however, 76942-26-59 was billed with a modifier.  
 
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 testing services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the ultrasound guidance is included in 
approved code 55706, 76942 with modifier 59 is not supported as separately identifiable. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Imaging services provided on July 18, 2022.
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 home ventilator. The Plan denied your request. The Plan says the enrollee 
has not failed BiPAP. 
 
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 physician 
reviewer found that the enrollee has severe COPD. The enrollee was recently hospitalized with pneumonia and 
non-ST-elevation myocardial infarction (NSTEMI). An arterial blood gas (ABG) during the hospitalization was 
consistent with chronic hypercarbic respiratory failure. There is no ABG done while stable to confirm this. If 
the enrollee does have chronic carbon dioxide retention, BiPAP during sleep may be beneficial. However, 
Medicare does not cover a home ventilator when used with settings that can be provided with BiPAP. 
Therefore, the requested ventilator is not medically 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. You say that 
thermal destruction of intraosseous basivertebral nerve is medically necessary. The Plan denied your request. 
The Plan says thermal destruction of intraosseous basivertebral nerve is experimental/investigative. 
 
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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested thermal destruction of intraosseous basivertebral 
nerve is not considered medically reasonable and necessary. Our physician reviewer found thermal destruction 
of intraosseous basivertebral nerve is considered experimental therapy at this time. Therefore, the request is 
deemed not 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 thermal destruction of intraosseous basivertebral nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve.
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 very weak and cannot walk on your own, 
and without the requested IRF services, your ability to regain maximum function will be seriously jeopardized. 
The Plan denied your request. The Plan says an 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 the documentation does not support the necessity for admission to an IRF and the 
complexity of your nursing, rehabilitation, and medical needs does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While you may have a need for 
physical therapy and/or occupational therapy, your rehabilitation needs can be provided in a lower intensity and 
alternate setting such as in an SNF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the wound has not healed after 30 days. 
The Plan denied your request. The Plan says the enrollee has not failed an adequate course of standard wound 
therapy. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy 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 that the enrollee has a diabetic foot ulcer, Wagner grade 3. The record does not provide primary 
source documentation of failure of adequate course of standard wound therapy as defined by Medicare rules. 
The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (PWC) (K0858) 
and accessories (E0955, E1002, E1028, E2310, E2361, E2608) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a PWC and accessories. You say that this equipment is necessary for the 
enrollee to continue living safely at home. The Plan denied your request. The Plan says this equipment is 
available in-network. 
 
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 a group 3 heavy duty power wheelchair (PWC) (K0858) and accessories (E0955, E1002, E1028, E2310, 
E2361, E2608) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple accessories 
and power options. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need for the power options included with the requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
provided records do not document the patient has a musculoskeletal condition or the presence of a cast or brace 
which prevents 90-degree flexion at the knee, or the patient has significant edema of the lower extremities that 
requires an elevating footrest. Provided records do not support that the patient is high risk for skin breakdown 
(he can walk about 20 feet with a single point cane), has a history of pressure ulcer(s) or has had skin flap 
surgery. Records do not document the patient performs bladder self-catheterization or that the patient has 
increased muscle tone or spasticity to meet criteria for the power tilt feature.  
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple accessories and power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this system is unproven among amputees and not medically necessary due to 
insufficient evidence of safety and/or efficacy. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has a transtibial amputation and requires a transtibial prosthesis for mobility and 
performing daily activities. He requires a new prosthetic socket due to changes in his residual limb. However, 
there is insufficient medical literature supporting the use of a prosthetic vacuum system. This may be appropriate for patients with frequent volume changes due to dialysis, but there is insufficient medical literature 
indicating that it significantly improves function with patients with excessive sweating. Therefore, the vacuum 
assisted socket system (L5871) is not medically 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum-assisted socket system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has had success in the past with 
this provider. The Plan denied your request. The Plan says the care the enrollee requires can be provided by a 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 You asked the Plan to pre-approve the compression stockings. You say that your provider says you need these 
compression stockings. The Plan denied your request. The Plan says you do not meet criteria for coverage of 
this item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin Aspart Flexpen (J1815). 
 
You asked the Plan to pre-approve the insulin Aspart Flexpen. The Plan denied your request. The Plan says this 
drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an insulin Aspart Flexpen 
(J1815).  
 
  Benefits for the insulin Aspart Flexpen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says that the enrollee must try and fail either an oral bisphosphonate drug OR 
zoledronic acid 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 Prolia. Our reviewer says that the 
requested Prolia is medically necessary. Our physician reviewer found the enrollee is with a history of 
osteoporosis. She has been on medical therapy with Prolia since November 2021. Her provider has 
recommended continuation of Prolia therapy. Medicare rules allow the plan to use step therapy. This is the 
process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-
formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an 
exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent 
with the prescriber's statement. The statement must show that the step therapy drugs have been ineffective in 
treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient 
compliance; or are likely to cause an adverse reaction or other harm to the enrollee. 
 
Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are 
not actively receiving the affected medication. In this case, the review has determined that Prolia is medically 
necessary and reasonable for treatment of the enrollee's osteoporosis 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.   
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 the outpatient L4-5 laminectomy back surgery (63047). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that the enrollee is in constant, worsening 
severe low back pain. Please see attached medical records. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for this procedure. 
 
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 outpatient surgery. 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 of recent physical therapy for back pain. More 
conservative measures are 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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient L4-5 laminectomy back surgery (63047).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 
enrollee does not meet the coverage criteria for Eylea. Our physician reviewer found based on the medical 
records provided there is no indication that the enrollee has tried and failed the required drug. Our reviewer 
also found that there is no indication that the Plan's required drug 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 (J0178).