Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-five (25) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the additional trips are 
necessary. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the 
Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 61st trip and beyond is not a covered benefit. The Plan contract says up to 60 one-way trips, combined in and out-of-network, are covered each year 
(limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve 
twenty-five (25) additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator generator (CPT code 63685). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not contain 
documentation from the enrollee's provider telling the Plan why the enrollee needs a new generator. 
 
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 services. Our physician reviewer 
found the medical records do not clearly document why a new stimulator generator is needed. More 
information is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the spinal cord stimulator generator (CPT code 63685).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the CardioMEMS system would not be considered medically appropriate and necessary 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 the device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
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 current equipment is not more than five years old or irreparably damaged. 
 
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. Medicare rules say that replacement durable medical equipment is covered in the 
case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of five years.  
The file shows that you have a power wheelchair that was provided by the Plan on November 11, 2021. The 
requested power wheelchair serves the same purpose as your current power wheelchair. The file does not show 
that your current power wheelchair is irreparably damaged or more than five years old. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for CPAP machine (A9270). 
 
You asked the Plan to pre-approve a battery backup. You say that you would like to appeal the denial because 
your mother has chronic conditions and is out of breath at night. The Plan denied your request. The Plan says 
Medicare does not allow payment for power generators or alternative power sources needed in the event of 
power outages. 
 
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 battery backup for CPAP machine (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the enrollee has suffered from this 
condition for 3+ years and it has greatly impacted their quality of life. The interspinous spacer (Vertiflex) 
received FDA approval in 2015. The Plan denied your request. The Plan says there is insufficient clinical 
evidence in the peer reviewed literature demonstrating the safety and efficacy of these procedures or 
demonstrating the effects of these procedures on long-term health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22869).
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 needs long term care and is 
not ready to go home yet. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and does not require transfer to an LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutritional therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says your diagnoses appear to be atrophy of thyroid 
(acquired), protein-calorie malnutrition and deficiency of other specified B group vitamins. The medical 
records received from your primary care physician does not indicate that you have renal (kidney) disease or 
diabetes.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutritional therapy services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiologic examination of the chest. 
 
You asked the Plan to pre-approve a radiologic examination of the chest. You say that the services are 
medically necessary. The Plan denied your request. The Plan says there is no preauthorization, no medical 
emergency or urgent care. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve a 
radiologic examination of the chest.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the enrollee to go to inpatient 
rehabilitation after discharge from the hospital. The Plan denied your request. The Plan says admission to the 
IRF was denied as not meeting criteria, is not medically necessary, and a lower level of care might be 
appropriate. Skilled nursing facility level of care was offered. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for COVID-19 pneumonia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87482 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 87482. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 87482 is 1. You billed 5 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of procedure code 87482 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87482 billed for date of service 
March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom orthopedic shoes (A5500). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you have exhausted the allowable benefit for these items.  
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The 
Plan contract says that for people with diabetes who have severe diabetic foot disease, one pair per calendar 
year of therapeutic custom-molded shoes are covered (including inserts provided with such shoes) and two 
additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-
customized removable inserts provided with such shoes). 
 
We reviewed the case file and the Plans rules. Based on this information, we have found that your request does 
not meet the Plans rules for coverage. Specifically, the Plan contract states that one pair of therapeutic custom-
molded shoes or depth shoes are covered per calendar year for people with diabetes who have severe diabetic 
foot disease. You previously received orthopedic shoes on May 24, 2022.  Therefore, you have exhausted the allowable benefit for these items. Therefore, we decided that the Plan does 
not have to pre-approve custom orthopedic shoes (A5500).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostate artery embolization is not medically reasonable and necessary in 
this case. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and 
efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting 
due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, 
postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with 
more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a colo-vesicular fistula and urinary tract infection. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammogram (77063, 77067) provided on May 
3, 2022. 
 
You asked the Plan to pay for the screening mammogram. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that only one screening mammogram is covered for 
women ages 35 to 39.  
 
We looked at the file and Medicare rules. The enrollee's age category is only eligible for coverage of 1 
screening mammogram. A screening mammogram was previously paid on April 21, 2021. Based on this 
information, we decided that Medicare rules for coverage of the screening mammogram have not been met. 
Therefore, we decided that the Plan does not have to pay for a screening mammogram (77063, 77067) provided 
on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision monitoring with a home device (ForeseeHOME) 
(0379T). 
 
You asked the Plan to pre-approve ForeseeHOME device. You say that the requested service is necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 ForeseeHOME device. Our reviewer 
says that the requested ForeseeHOME device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found in accordance with Social Security Act, Section 1862, vision monitoring with the 
ForeseeHOME (0379T) is still being studied to detect changes in vision with macular degeneration. Therefore, 
the reviewer found that the requested device 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 ForeseeHOME device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vision monitoring with a home device (ForeseeHOME) (0379T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this PCD was used in the ambulatory surgery setting to 
prevent thromboembolism. This service is not covered under the DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673 RT&LT) provided to the enrollee on March 7, 2022. 
 
You asked the Plan to pay for the services. You say that you do not agree with the denial. The Plan denied your 
request. The Plan says this is not covered since the place of service is an ambulatory surgical center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the device was used in a SNF or hospital. Therefore, we decided that the Plan does not have 
to pay for a segmental gradient pressure pneumatic appliance, half leg (E0673 RT&LT) provided to the 
enrollee on March 7, 2022.