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

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says you do not have a movement problem that keeps you from being able to do normal 
activities in your home. You state that you are not at high risk for falls or injuries while trying to do normal 
activities in your home. 
 
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 DME. Our physician reviewer 
found there is no documentation that you have a personal mobility deficit that impairs participation in mobility 
related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within 
the home. Records just indicate difficulty with walking longer distances. There is no documentation that your 
mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. A cane has been ordered 
for you by your medical provider. There is no documentation that you can safely operate a power mobility 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (CPT code K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a basic 
compression device has not been tried. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
The file shows that a pneumatic compression device, coded E0652, was requested. We looked at the file and 
Medicare rules. The records provided do not show that the enrollee failed to improve after a four-week trial of 
a standard compression device coded E0650/E0651. 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 pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic shoes and inserts to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME vendor said they could not get paid by the 
health plan for these patients. The Plan denied your request. The Plan says there are in-network provider(s) able 
to provide this service within a reasonable distance from your location. 
 
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 
the diabetic shoes and inserts to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing provided on November 3, 2021. 
 
You asked the Plan to pay for specimen validity testing. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
specimen validity testing is not separately payable and the record does not support use of the -59 modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of specimen validity testing have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for specimen validity testing provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair push handles (K0108). 
 
You asked the Plan to pre-approve the wheelchair push handles. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the push handles are not DME as they are not primarily 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 the wheelchair push handles (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A Life Alert Telephone Alert System. 
 
You asked the Plan to pre-approve A Life Alert Telephone Alert System. You say that emergency 
communications systems do not serve a diagnostic or therapeutic purpose. The Plan denied your request. The 
Plan says emergency communications systems do not serve a diagnostic or therapeutic purpose. 
 
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 Life Alert Telephone Alert System.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Enteral formula. 
 
You asked the Plan to pre-approve Enteral formula. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services are not covered. 
 
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, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested Enteral formula. Therefore, we 
decided that the Plan has to pre-approve Enteral formula.  
 
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 gradient compression stockings identified with code 
A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item is needed for treatment. 
The Plan denied your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
We looked at the file and the rules. Although this item may be appropriate, it does not fall into a covered 
benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not 
have to pre-approve gradient compression stockings identified with code A6549.
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. The Plan denied your request. The Plan says the 
LTACH services you are requesting do not meet the requirements for approval. 
 
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 you do not require services at the LTACH that are not already available at the current 
facility. Our reviewer found that there are no services at the LTACH that you require that are not already 
available and covered at the current facility. Our physician reviewer also found that transfer to an LTACH is 
not medically necessary, as it would not be clinically advantageous. Transfer may be considered when 
treatment has completed. 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not covered for your condition. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You were recently admitted in diabetic 
ketoacidosis. Shortly after admission you had an acute syncopal episode with hypoxia and bradycardia, and 
briefly received CPR. Arterial blood gases (ABG) after this event showed mild CO2 retention that persisted. 
COPD is mentioned as a possibility, but you are a nonsmoker and had a venous PvCO2 of 30 prior to the 
episode, there are no pulmonary function tests, and CXR was normal, so COPD is unlikely.  You do not have a diagnosis for which Medicare covers a home ventilator, such as thoracic restrictive disease 
or neuromuscular disease. There has been no ABG done as an outpatient when you were stable. Obstructive 
sleep apnea is suspected. A BiPAP has not been tried. Our physician reviewer found that your condition does 
not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right knee genicular nerve block (CPT code 64454). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is status post knee replacement with 
nine (9) past surgeries on the same knee. You state the enrollee has failed other conservative measures and the 
last genicular nerve block done January 31, 2018, helped reduce the enrollee's pain by 50% until recently. The 
Plan denied your request. The Plan says this procedure is experimental and investigational due to a lack of 
scientific evidence regarding the effectiveness of a genicular nerve block/RFA for the knee. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/ investigative procedure whose role in knee pain is still being 
considered. Therefore, the request is deemed 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the right knee genicular nerve block (CPT code 64454).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 17, 2021, 
through September 11, 2021. 
 
You asked the Plan to pay for the home health services. You say that this should be paid because the dates of 
services reported on the claim are correct. The Plan denied your request. The Plan says home health payments 
are made based on 30-day episodes of care. This claim is for a 57-day episode, which is not payable under the 
home health prospective payment system. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services are billed and paid in 30-
day episodes. The claim cannot be for a span of more than 30 days.  
 
We looked at the file and Medicare rules. The date span being billed is more than 30 days. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from July 17, 
2021, through September 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items should be covered. The Plan 
denied your request. The Plan says the Health Plan and Medicare do not cover incontinence supplies because 
they are disposable, non-reusable hygiene items and fall outside the scope of coverage. 
 
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 incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) 
unit. 
 
You asked the Plan to pre-approve a TENS unit. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the member is not in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of inclusion in an approved 
clinical study, TENS is not reasonable and necessary for the treatment of CLBP. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Transcutaneous Electrical Nerve Stimulation (TENS) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest oscillation vest (E0483). 
 
You asked the Plan to pre-approve a chest oscillation vest. You say that the member wants a different model of 
his vest. The Plan denied your request. The Plan says duplicate or backup equipment is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a chest oscillation vest. a chest oscillation vest serves the same purpose as a 
chest oscillation vest. Therefore, we decided that the Plan does not have to pre-approve a chest oscillation vest 
(E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you forget to monitor your blood sugar 
frequently. The Plan denied your request. The Plan says you have not met the criteria. 
 
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 does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
result. 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 pre-approve a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the SNF services 
you are requesting do not meet the requirements for approval. 
 
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 services. Our reviewer says that 
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve large intestine disorder testing (CPT code(s): 82397 and 
83520). 
 
You asked the Plan to pre-approve the laboratory testing. You say that all of your doctors agreed you need to 
have this test done before you can be prescribed medication. The Plan denied your request. The Plan says the 
services are not medically reasonable or necessary. 
 
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 laboratory testing. Our physician 
reviewer found there is no specific clinical rationale for the requested testing. You have IBS-D. The review 
indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve large intestine disorder testing (CPT code(s): 82397 and 83520).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G powered upper extremity range 
of motion assist orthosis (CPT code L8702). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the item/service at issue in this case 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro 2 Motion G powered upper extremity range of motion assist orthosis (CPT 
code L8702).